Provider Demographics
NPI:1063704138
Name:JUDY, SHANE F
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:F
Last Name:JUDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:PA
Mailing Address - Zip Code:16323-1215
Mailing Address - Country:US
Mailing Address - Phone:814-432-4824
Mailing Address - Fax:814-437-2312
Practice Address - Street 1:1020 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323
Practice Address - Country:US
Practice Address - Phone:814-432-4824
Practice Address - Fax:814-437-2312
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP-044646-R183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist